Conversations With Prostate Cancer Experts

When Anxiety Impacts Treatment

Dr. John Peteet is a staff psychiatrist at Brigham and Women’s Hospital, and Dana-Farber Cancer Institute, and an Associate Professor of Psychiatry at Harvard Medical School.

Prostatepedia spoke with him about the anxiety and depression many prostate cancer patients face.

Are there common themes or issues that many cancer patients face?

Dr. Peteet: Anxiety around the time of diagnosis is a common theme. It tends to diminish when patients receive a treatment plan, especially if the treatment starts to have some effect. A treatment response provides time for patients to stabilize their functioning and their expectations.

Recurrence is, of course, distressing, but when a treatment works for the recurrence, this typically decreases anxiety and distress.

Then, if treatments ultimately fail, it’s stressful to face discussions about goals of care and what to do with one’s limited time.

In general, when patients lose their ability to function in ways that have been central to their identity—for example, becoming unable to work—they tend to need more help.

Are there issues specific to prostate cancer? There is a fair amount of uncertainty about what the appropriate treatment path might be for certain groups of prostate cancer patients. Does that create a special challenge in prostate cancer?

Dr. Peteet: Some decisions about course of treatment for breast cancer make women anxious, but anxiety about course of treatment is a particular issue in prostate cancer because patients can get so many differing opinions: radiation versus surgery versus watchful waiting. There’s also considerable apprehension on the part of many men about the potential side effects of some of those treatments—especially sexual dysfunction and incontinence.

After treatment, it is anxiety-provoking every time a man returns to see what his PSA indicates that his cancer is doing.

Making decisions about systemic treatment after a recurrence can be difficult because of the concern about side effects. For example, there is sometimes a risk of depression with hormone deprivation therapies, such as Lupron (leuprolide). If a man has a history of depression, he might be particularly vulnerable to depression, or a worsening mood disorder.

I know for many men it can be frightening to see their PSA go up a little bit after treatment: What does it mean? Is my cancer coming back? Is it a temporary bump? What would you say to men who are experiencing that kind of anxiety about PSA testing after treatment? Are there any techniques you would recommend to manage PSA anxiety?

It’s important for men to talk to somebody they trust, who follows the PSA along with them, whether that’s an oncologist, a radiation oncologist, or a urologist. Those doctors would be the ones most involved. Sometimes support groups are helpful for men to just share what the experience is like with other guys.

Do these kinds of issues impact the kind of choices men make? We have another conversation this month in which we talk about how many people come off active surveillance because they’re nervous about whether the cancer is progressing or not.

Dr. Peteet: I have seen a few men unwilling, or very reluctant, to have hormone deprivation treatment because they were concerned about what it would do to their bodies. For example, weightlifters, bodybuilders, or men who are very invested in their sexual functioning, might turn that therapy down.

There are also occasionally men who don’t want to get tested in the first place, don’t want to have a surgery they think will impair their functioning in those ways, or put off treatment. Usually, there are other choices like radiation that are more palatable to them.

So yes, I think it does impact treatment. Their values about what is most important to them do influence the treatment choices they make.

Some men don’t care about side effects. They want to get the cancer out. They might be more apt to choose surgery while somebody else who is more concerned about those other issues might go in a different direction.